Woo 6 METROPOLITAN BOROUGH OF WOOLWICH ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH SIDNEY DAVIES., M.A., M.D., Oxon.; D.P.H. Camb. 1918. SUMMARY OF STATISTICS, 1918. Area of Borough 8,276.6 acres Population — Census, 1911 121,376 do. estimated to middle of 1918, civil 146,503 Total 155,576 Inhabited Houses—Census, 1911 21,463 Persons to an acre 14.7 Persons to a House—Census, 1911 5.65 Marriages 1,484 Births 2,578 Birth Rate 16.5 Deaths 2,092 Death Rate 14.3 Infantile Mortality, per 1,000 births 104 PREFACE. To the Mayor. Aldermen and Councillors of the Metropolitan Borough of Woolwich. Mr, Mayor, Ladies and Gentlemen. I have the honour to present you with my 18th Annual Report on the Health of Woolwich, including the 28th Annual Report for Plumstead. The report is again abbreviated owing to the high cost of printing and the usual tables are omitted. They have, however, been prepared and are kept for reference. The Borough, like the rest of England, experienced an exceptionally high death rate due to the severe epidemic of Influenza which visited London in October. The infant mortality rose in 1918 even more than the general death rate. In 1917, although for the first time Woolwich had the lowest infant mortality of any Metropolitan Borough, it was noticeable that the infant mortality had not declined as much as the general death rate. In 1918 there was a marked increase of the illegitimate birth rate, the death rate of illegitimate infants, the deaths under one week and the deaths from Puerperal Fever. I believe that sexual immorality and illegitimacy—which is much greater than appears from official returns—are a main cause that infant mortality has not declined as much as might be hoped. Though there has been a very great improvement in the Public Health during my tenure of office there is ample room for further advance, and the subject of illegitimacy is one which calls for serious attention. In presenting this, my last Annual Report, I have to acknowledge with thanks the support which your Council has given to my many proposals for improving the public health, and hope that my successor may have your whole-hearted cooperation in his efforts to further reduce disease and increase the public health find welfare. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient Servant, SIDNEY DAVIES. EIGHTEENTH ANNUAL REPORT on the HEALTH OF THE METROPOLITAN BOROUGH OF WOOLWICH Year ending 31st. December, 1918. PART 1. STATISTICS Population. 1. The population of the Borough of Woolwich, as estimated at the Census of 1911, was 121,376. The estimated civil population to the middle of 1917 was 146,503. The same population has been taken for 1918, as there has been no increase of housing accommodation, and no known diminution or increase of inhabitants. The population of the four Registration Districts at the last three Censuses and the present estimated population is as follows:- Census 1891 Census 1901 Census 1911 Estimated to middle of 1918 Woolwich Parish 40,848 41,625 36,710 33,605 Plumstead Parish: West 52,436 38,569 40,328 43,098 East 29,758 30,888 39,424 Eltham Parish 5,710 7,226 13,450 30,376 98,994 117,178 121,376 146,503 The following figures show how the number of persons to a house in Woolwioh and Plumstead has varied during the past four Censuses:- 1  WOOLWICH PLUMSTEAD Census, 1891 — 6.08 „ 1896 - 6.14 „ 1901 7.85 6.05 „ 1911 7.27 5.34 2. The estimated population of soldiers in barracks in June, 1918, was 9,073, making the total population 155,576. The civil population is used for all statistical rates except the Borough birth rate. The Registrar-General estimates the civil population at 134,453, and the total at 150,650. In the Annual Report for 1913, on pages 15 to 19, tables were given showing the age distribution and condition as to marriage of the population, the proportion of males and females compared with London and England, and the classification of buildings, and in the Report for 1914, the number to a house in each Ward. 3. The following table shows the number of new houses certified for water each year since the Census of 1911:- New Houses, April 1st. to June 30th, 1911 34 „„ July 1st. 1911 to June 30th, 1912 93 „ „ July 1st. 1912 to June 30th, 1913 141 „ „ July 1st. 1913 to June 30th. 1914 254 „ „ July 1st. 1914 to June 30th. 1915 170 „ „ July 1st. 1915 to June 30th. 1916 139 „ „ July 1st. 1916 to June 30th. 1917 36 „ „ July 1st. 1917 to June 30th. 1918 3 The following are the numbers of new houses and huts erected by the Government for Munition Workers from 1915-1917:- Houses 1,269 Huts, 1,904. 4. Unoccupied Houses. At the 1901 Census, there were 234 unoccupied houses in the Borough, viz., 46 in Woolwich, 86 in Plumstead, and 102 in Eltham. At the 1911 Census there were 1,296, viz., 450 in Woolwich, 387 in West Plumstead, 250 in East Plumstead, and 209 in Eltham. In January, 1916, the Rate Collectors found 57 houses unoccupied, viz., 7 in Woolwich, 13 in West Plumstead, 5 in East Plumstead, and 32 in Eltham. There are now practically no houses fit for occupation to let. The Government Huts, though so much criticised, are all full and there is a long waiting list of applicants wishing to occupy them. 2 BIRTHS. 5. The number of births was 2,578, viz., 662 in Woolwich parish, 665 in West Plumstead, 710 in Bast Plumstead, and 541 in Eltham (corrected for children bom in the Infirmary, and the Wood Street Home for Mothers and Babies, whose parents reside outside the Borough, and births in outlying institutions). The birth rate (calculated on the total population) 16.5 compares with 17.1 in 1917. The rate for the County of London was 16.1. Notification of Births. 2,418 live births were notified under the Notification of Births Act (1,238 males, 1,172 females, 8 not stated). This is at the rate of 94 per cent of the registered births, compared with 92, 89, 97, 86 and 95 per cent in the five preceding years. 1,515 births were notified by midwives, 137 by the Hospital for Mothers and Babies, 340 by medical practitioners and 303 by other persons. 70 still.births were notified (79, 59, 75, 77 and 88 in 1913 to 1917 respectively). Of the still.bom, 37 were males and 33 females. The Notification of Births Act was adopted on March 1st. 1908. There were 160 births last year which were not notified. All the parents, midwives and Doctors who neglected to notify were cautioned. The excuse generally given by the midwife was, that the notification must have been lost in the post, and by the Doctor, forgetfulness. The parents either did not know their responsibility, or thought it had been discharged by the professional attendant. 6. The following table gives the birth rate of the borough during the years 1901-5, 1906-10, 1911-1915, 1916, 1917 and 1918, and, for the purposes of comparison, the corresponding rates of the neighbouring Boroughs, London and England:- BIRTH RATE. 1901-55 1906-10 1911-15 1916 1917 1918 Greenwich Borough 27.6 26.5 25.1 24.6 21.1 17.5 Lewisham „ 25.7 23.3 20.2 20.4 16.5 14.6 West Ham „ 33.1 31.4 29.7 28.8 23.2 22.4 East Ham „ 33.8 — 24.4 22.1 18.5 15.1 Erith 34.1 — 24.8 23.1 80.0 18.8 London 28.2 26.5 24.7 23.0 17.4 16.1 England and Wales 28.2 26.0 23.5 21.6 17.8 17.7 Woolwich Borough 29.2 25.3 22.2 21.7 17.1 16.5 3 7. The following table gives the birth-rate for the Borough and each Registration District for the five past quinquennia and for 1916, 1917 and 1918, the rates for the Registration Districts being calculated on the civil population. Correction has been made for births in the Infimary, the Wood Street Home for Mothers and Babies and outlying institutions, and the births distributed to the parishes to which they properly belong. West Plumstead and Eltham had the lowest birth-rate of the four Registration Districts. Although the birth-rate in Eltham has fallen very much since 1916. it was still higher than in the five years 1911-15. The greatest decrease since 1911-15 is in the parishes of Woolwich and West Plumstead. 1891 to 1895 1896 to 1900 1901 to 1905 1906 to 1910 1911 to 1915 1916 1917 1918 Woolwich Borough 32.5 30.2 29.2 25.3 22.2 21.7 17.1 16.5x Woolwich Parish 31.1 30.1 29.0 27.9 25.2 21.5 19.6 19.7ø Plumstead.West 33.3 31.0 30.1 24.7 20.7 21.6 17.4 15.4ø East 22.7 20.5 18.7 18.01ø Eltham Parish 22.8 20.6 24.0 21.6 17.3 23.5 18.2 17.8ø xTotal population used. øCivil population used; number of soldiers not known, but very small. 8. Illegitimate Births. 98 of the births registered were illegitimate, giving a rate of 38 per 1,000 births, compared with 23, 21, 29, 34 and 37 in the five preceding years, MARRIAGES. 9. There were 1,484 marriages. The marriage rate was 20.2 compared with 17.7, 27.1, 23.7 ana 19.7 in the four preceding years. The marriage rate in England and Wales in 1917 was 13.8 and was the lowest on record. DEATHS. 10. Table 1 gives the gross and net deaths and death rates in 1918 and each of the past sixteen years, and shows how the net deaths are arrived at. 11, The net deaths were 2,092, and the net death-rate 14.3 compared with 12.3 and 10.6 in the two preceding years, and 12.5 4 the average of the ten years 1905-1914. This is the highest rate recorded since 1902. 12. The following table shows the death-rate of Woolwich compared with London and the adjoining Boroughs:- 1917 1918 England and Wales 14.4 17.6 96 great towns 14.6 18.2 London 15.0 18.9 Greenwich 15.1 18.8 Lewisham 11.6 13.6 West Ham 14.5 19.9 East Ham 11.4 14.5 Erith 9.6 12.7 WOOLWICH 10.6 14.3 In 1917 Woolwich had the lowest death-rate of all the Metropolitan Boroughs; last year three Boroughs had a lower death rate, viz., Hampstead, Wandsworth and Lewisham, 13. The following table gives the average death-rate in each Registration District of the Borough during the past six quinquennial periods, 1916, 1917 and 1918. Woolwich parish had the highest death rate and Eltham the lowest. 1886 to 1890 1891 to 1895 1896 to 1900 1901 to 1905 1906 to 1910 1911 to 1915 1916 1917 1918 Woolwich Borough 17.2 16.9 13.9 12.5 12.7 12.3 10.6 14.3 Woolwich Parish 20.4 19.3 20.1 16.5 14.8 14.9 14.3 13.9 18.1 Plumstead.West 16.4 16.0 15.1 12.9 12.0 13.2 12.6 11.8 15.5 East 11.8 10.2 8.4 12.4 Eltham Parish — 13.0 14.6 10.2 10.1 8.9 8.5 8.0 10.8 London 20.0 19.8 18.5 10.1 14.9 14.7 14.3 15.0 18.7 KThree years—1888, 1889 and 1890. 14. The following tables give the numbers dying at various ages in the past sixteen years from all causes and Influenza, and the deaths at all ages from certain diseases, not hereafter referred to:- 5 Annual Deaths — l903-l918. Year Age Period Under 1 1-5 5-10 10-15 15-20 20-25 25-35 35-45 45-55 55-65 65-75 75 & over 1903-7 aver. 402.4 162.8 43.4 27 31.4 44.8 104.2 138.4 155.6 174.8 201.4 171 1908-12 aver. 250.4 131.4 41.4 23.4 33.2 33.2 87.4 127 146.6 199.2 211.6 203.8 1913 229 93 34 25 44 48 109 134 177 208 240 239 1914 239 141 52 33 47 35 97 147 184 225 246 244 1915 268 136 62 28 47 41 93 170 210 246 269 263 1916 215 105 40 33 41 37 99 160 200 224 269 260 1917 214 113 28 34 41 33 96 116 179 221 243 232 1918 268 169 80 57 73 89 232 206 217 223 234 244 Influenza 11 31 36 21 35 33 131 57 43 21 23 12 Deaths from Average Average 1913 1914 1915 1916 1917 1918 1903-7 1908-12 Apoplexy and all otherdiseases of the heart and blood vessels 217.4 258.8 312 332 351 319 283 258 Nephritis and Bright's disease 44 47 57 46 47 45 48 43 Respiratory diseases -all forms (expect phthisis) 260.8 228.4 254 287 385 299 302 350 15. The Natural Increase of the population. In spite of the high mortality—Woolwich—more fortunate than many towns. had an excess of births over deaths of 486 compared with 1,148 in 1917. INFANT MORTALITY 16. The deaths under one year were 268 compared with 214 in 1917. The infant mortality (deaths under one year per 1,000 births) was 104. This is the highest rate recorded since 1907. 6 The following table gives the infantile mortality in the Borough since 1901, compared with the neighbouring Boroughs, London and England:- 1901 -5 1906 -10 1911 -15 1916 1917 1918 Lewisham 112 92 81 72 87 66 Greenwich 107 112 103 83 101 116 West Ham 158 126 114 98 105 114 East Ham 131 106 80 78 85 66 Erith 112 80 77 60 83 82 London 138 114 108 89 103 107 97 great towns 127 117 98 104 106 England & Wales 135 115 109 91 97 97 WOOLWICH BOROUGH 119 97 86 70 79 104 Though the rate was lower In Woolwich than in London, the difference was very little. The Woolwich rate was unusually high, both absolutely and relatively to London. 17. The following table gives the infantile mortality during the past two years, and the six preceding quinquennia in the Borough and each Registration District. 1886 to 1810 1891 to 1895 1896 to 1900 1901 to 1905 1906 to 1910 1911 to 1915 1916 1917 1918 Woolwich Parish 151 157 170 134 109 101 84 97 125 Plumstead-West 121 120 132 113 91 75 54 70 99 East 81 65 84 85 Eltham — 163 160 97 89 67 83 67 109 Woolwich Borough 140 146 119 97 86 70 79 104 x 1888, 1889 and 1890. Woolwich Parish and Elthem had the highest mortality, and East Plumstead the lowest. 18. Table IV. gives full details as to the ages at death and causes of death of the infants dying in 1918 under one year. It shows that 41 per cent of those who died under one year were under one month old, compared with 42 per cent in 1917, 49 per cent in 1916, and 37 per cent in the previous ten years; 69 deaths were from premature birth, compared with 41, 53, 55, 55, and 49, in the five preceding years. The number of deaths under one week in the past five years was 68, 55, 73, 57 and 73, respectively. 7 The number of deaths from suffocation was 5 compared with five in 1917 and nil in 1916. In the previous four years the deaths from suffocation in bed averaged four a year, and in the four years 1904-7 they averaged 7. Two of the five deaths which occurred in 1918 took place at birth and were apparently due to lack of proper attention, and not to overlying. The death rate per 1,000 births from premature birth in Woolwich Borough was 22.9 compared with 14.2, 20.5, 19.5, 17.9 and 17.8 in the five preceding years. In London it was 19.5 in 1917. There were 34 deaths of illegitimate infants. The death-rate of illegitimate infants under one year was 347 per 1,000 births (compared with 218 in 1917) and that of legitimate children 94. This great increase in the illegitimate death-rate and the increase of the premature birth-rate are disquieting facts. 19, Compared with 1917 the past year had among infants more deaths from premature births injury at birth, enteritis, bronchitis, meningitis, whooping cough and influenza. 20. Deaths between 1 and 5 years. 81 deaths (57 in 1917) ocourred between 1 and 3 years, and 88 (56 in 1917) between 2 and 5). The death-rate between 1 and 5 was 16.3 per 1,000 children of that age found at the Census (viz., 10,357) compared with 13.1, 10.1, and 13.6, in the three previous years. Too much emphasis must not be attached to this apparent increase which is no doubt largely due to increase of population. 21. Zymotic Death-rate. The number of deaths from scarlet fever, diphtheria, measles, whooping cough, enteric fever, and from diarrhoea and enteritis (under 2 years of age as regards diarrhoea and enteritis), was 105, and the death rate per 1,000 population 0.72, compared with 0.95, 0.85, and 0.69, in the three previous years. The zymotic death rate has fallen greatly since 1901, when it was 1.51. 22. INQUESTS. There were 112 inquests, compared with 123. 146, 180, l81 and 131, in the five preceding years. 8 The following table gives particulars as to the cause of death 1. Natural causes • • • 57 2, Alcoholism • • • 1 3. Accidental Causes Burns and Scalds 4 Drowning 3 Vehicular traffic (a) By road 10 (b) By rail 2 Explosions 8 Suffocation-Overlying 3 Other Accidental causes 18 48 4. Homicidal Cases Suicide 4 Murder and Manslaughter 2 6 112 The "Accidental Causes" were 37, 39, 63, and 52, in the four preceding years. The "Homicidal Causes" were 21, 13, 12, and 7, in the same years. The reduction of accidents and homicide; is very satisfactory. The death-rate from violence was 0.37 compared with 0.56 in London. SMALL-POX. 23. Not a single case of small-pox was notified in Woolwich. 35 cases were notified in London. In view of the possible spread of the disease to this district the Medical Officer of Health was authorised to arrange for the maintenance and observation of contacts at the Health Shelter. The Local Government Board has authorised all Medical Officers of Health to vaccinate contacts who require it. MEASLES. 24. There were 21 deaths from Measles, giving a rate of 0.14, compared with 0.33, 0.17 and 0.21 in the three preceding years. -The rate in London County was 0.42. 25. Of the 21 who died from measles, 20 were under five years of age. 26, 800 notifications were received under the Local Government Board Order, compared with 1,590 and 1,710 in 1916 and 1917. 9 . The mortality per cent of notifications was 2.3, compared with 1.4 and 1.8 in the two preceding years. 12 cases were removed to the Fever Hospital on the certificate of the Medical Officer of Health that isolation was necessary, compared with 10 in 1916 and 45 in 1917. 27. The following table gives the number of deaths and deathrates from measles for the past three years, and five preceding quinquennia in each parish and the death-rate in London:- Year Woolwich Plumstead Eltham The Borough London Aver. No. Rate Aver. No. Rate Aver. No. Rate Aver. No, Rate Rate. 1891-5 20 0.49 29 0.51 Not recorded 49 0.51 0.59 1896-1900 34 0.81 36 0.57 Not recorded 70 0.67 0.57 1901-5 9 0.22 15 0.22 1 0.13 26 0.21 0.44 1906-10 17 0.43 18 0.23 3 0.20 37 0.30 0.40 1911-15 12 0.30 14 0.19 2 0.13 27 0.21 0.42 1916 8 0.24 15 0.19 — — 23 0.17 0.19 1917 13 0.39 11 0.16 7 0.23 31 0.21 0.48 1918 13 0.39 7 0.09 1 0.03 21 0.14 0.42 The actual reduction in Measles mortality is not so large as appears from the above table, owing to the fact that the falling birth rate has caused a diminution in the number of children living under five years, but it is very satisfactory to find that the death rate is still falling. The following table, giving the deaths and death-rates per 1,000 births, shows the reduction more nearly but not sufficiently favourably:- No. Rate 1891-95 (average) 40 14.7 1896-1900 70 20.9 1901-05 26 7.2 1906-10 37 11.8 1911-15 27 9.8 1916 23 7.5 1917 31 11.5 1918 21 8.1 It appears from these tables that, whereas from 18911900 Woolwich had a somewhat higher measles' mortality than London, since that date the measles death-rate has greatly diminished, and diminished much more in Woolwich than in London. 10 28, To prevent the spread of measles In school, the Medical Offioer of,the London County Oounc.il continued to close, or exclude unprotected children from classes on the occurrence of one or more cases; The period of exclusion or closure was usually for a few days only, in some cases for two weeks. 28a, Notification, By Order of the Local Government Board made under S. 130. P.H.A,, 1875, Measles and German Measles were made compulsorily notifiable from January 1st, 1916, (See Council's Minutes, December 22nd, page 93). 800 oases of Measles were notified compared with 1,710 in 1917, Of these 452 were under five years of age, 316 between five and fifteen, and 32 over 15, The largest number of notifications was in Woolwich Parish, viz., 592. In addition* 113 oases of German Measles were notified. The cost of notification was £21. 13. 0. The case mortality was 2.6, In Woolwich parish it was 4.0, In Plumstead 1.9 and in Eltham 0.8, The Health Visitors visited all notified cases , gave advice as to isolation, cleanliness, ventilation, etc., and where it seemed desirable, and the friends approved, the District Nurse was requested to attend, 100 cases were nursed compared with 139 in 1917. These visits were paid for by the Borough Council, according to the arrangements made in 1916, at a cost of £35. 5. 2. 12 oases were admitted to a Fever Hospital on the special recommendation of the Medical Officer of Health, WHOOPING COUGH. 29, There were 29 deaths from Whooping Cough, The deathrate was 0.20, compared with 0.03, 0.25, and 0.07, in the three preceding years, and 0.43 in the County of London, 23 of the children who died were under two years of age. The following table gives the deaths and death-rates per 1,000. population since the Borough was formed, compared with London. 11  Woolwich London Rate No. Rate 1901-05 (averages 34 0.28 0.35 1906-10 26 0.2l 0.29 1911-15 17 0.14 0.21 1916 34 0.25 0.18 1917 10 0.07 0.13 1918 29 0.20 0.43 The death-rate per 1,000 births was 11.2, oompared with 11.1 and 3.7 in 1916 and 1917. In 1913 an Order was issued by the Local Government Board giving permission to the Asylums Board to admit to their hospitals children under 14 suffering from whooping-cough, on the recommendation of the Medical Officer of Health. Instructions printed on cards are left at houses where cases are notified by sohool teachers. The instructions were printed in the Annual Report for 1910. SCARLET FEVER. 30. There were 217 oases of Scarlet Fever notified (deducting 5 cases of mistaken diagnosis) equivalent to a rate of 1.48 per 1.000 population. This compares with 0.99 in 1917, but is otherwise the lowest rate recorded. 31, The following table shows the case-rates of scarlet fever in the Borough and each Registration District during the past eighteen years, compared with London:- Average 1901 1906 1911 1912 1913 1914 1915 1916 1917 1918 -5 -10 borough 3.15 5.90 4.09 3.80 4.80 5.46 4.31 1.69 0.99 1.48 Woolwich parish 2.99 5.66 2.89 2.41 5.44 6.11 4.48 1.94 1.19 2.80 Plumstead West 3.24 6.33 3.77 4.96 4.68 5.45 4.0 1.30 0.84 1.25 East 7.51 4.88 5.11 4.18 6.55 1.98 0.74 0.99 Eltham parish 3.21 4.94 2.09 2.64 4.36 7.45 3.85 1.67 1.38 1.18 London County 3.57 4.22 2.32 1.76 3.89 5.53 3.94 2.06 1.52 1.70 12 32, Table III gives the age distribution, the number in each parish, and the number removed to hospital. Woolwich Parish was most affected. 33. Deaths. There were four deaths, giving a death-rate of 0.03 per cent compared with 0.06, 0.03, and 0.01, in the three previous years, 0.08 in the five years 1908-12, and 0.19 in the ten years 1891-1900. The death-rate in London was 0.03 compared with 0.02 in 1917. The case mortality (or deaths per cent of notifications) was 1.8 compared with 1.3, 1.4 and 1.7 in the three preceding years. 34. Hospital Isolation. Of the 222 cases notified, 189 (or 85 per cent) were removed to one of the fever hospitals, compared with 90, 88, 85, 91 and 85 per cent, in the five preceding years. 35, HOME ISOLATION. 21 certificates of efficient home isolation were given to enable men to continue their employment in the Arsenal, and so obviate unnecessary removal to hospital, compared with 15, .18, and 6, in the three preceding years. In the Annual Report for 1911 a comparison was made between home and hospital isolation, showing that, whereas there were only 1.6 per cent of failures in home isolation, there were 4.6 per cent in hospital isolation. Failure means the occurrence of seoondary cases attributed to the primary case. 36. The Annual Report for 1905 contained a special report on a statistical investigation into school incidence of scarlet fever and diphtheria during the ten years 1896-1905. DIPHTHERIA. 37. 208 cases of diphtheria were notified (excluding 32 oases of mistaken diagnosis). The case-rate (number of cases per 1,000 population), corrected for oases of mistaken diagnosis , was 1.42 oompared with 1.77, 1.81 and 1.65 in the three preceding years, and 1.99, the average of the ten years 1901-10. This is the lowest case-rate recorded since 1910. 38. There were 25 deaths, compared with 11 and 16 in 1916 and 1917. The death rate was 0.17 compared with 0.26, 0.15, 0.08 and 0.11, in the four preceding years. 13 The London death-rate was 0*17, 39, 71 of the total cases notified were in Woolwich parish, 75 in West Plumstead, 54 in East Plumstead, and 40 in Eltham. The following table shows the case-rate in each registration district (not corrected for mistaken diagnosis) in the past seventeen years, compared with London and the Borough:- 1901 1906 1911 1912 1913 1914 1915 1916 1917 1918 -5 -10 Borough 1.71 2.20 1.68 3.09 1.91 2.72 1.77 1.81 1.65 1.42 Woolwich Parish 1.63 2.34 2.40 4.38 4.43 4.92 2.23 2.80 1.76 2.11 Plumstead Parish 1.87 2.40 (W1.19 3.79 2.32 3.33 1.99 2.11) 1.60 1.74 (E2.33 2.81 1.02 2.39 2.87 1. 23 ) 1.50 1.37 Eltham Parish 1.62 2.22 2-30 1.71 1.29 3.33 0.88 1.72 2.96 1.32 London 1.90 1.63 1.64 1.57 1.70 2.02 2.01 2.04 2.06 2.03 East Plumstead had the lowest rate. 40. 227 oases, or 93 per cent of total notifications, were removed to hospital, compared with 94, 92, 91, and 91, per cent in the four preceding years. A certificate of efficient home isolation was given in 7 cases, compared with 1, 7, 10, 8, and 4, in the five preceding years. The case-mortality was 12.0 per cent, compared with 7.0, 9.7, 8.3, 4.4, and 6.6, in the five preceding years. 14 carrier cases, with or without slignt symptoms, were discovered by your Medical Officer of Health. The usual steps were taken. 57, or 24 per cent of the cases notified, were over 15 years of age. In the last seven years there has been a marked increase in the proportion of Diphtheria notifications over school age. In 1911 the percentage was only 13 and there has been a steady increase since. There is no similar increase in the rest of London, and it is probably connected with changed age distribution of the population, and increased provision for discovering infeotious disease among munition workers. A small outbreak, comprising 13 cases, occurred at the Central Schools; the children attending were examined by the L.C.0. Medical Officer and a large number of absentees by the Medical Officer of Health. Two of the former and four of the latter were discovered to be carriers of infection and on their isolation the outbreak ceased. 14 41. Mistaken Diagnosis. 32 oases, or 13 per cent of notifications, were, after removal to hospital, stated to be not diphtheria. The percentage of the four preceding years was 16, 15, 8, and 13, respectively. 42. Wilful Exposure. A boy after exposure to infection in another Borough was found to have congested throat and Diphtheria bacilli. He was notified and the parents warned. In spite of this he was repeatedly exposed in the street. The mother was prosecuted and fined 21/- and 42/- costs. 43. Bacteriological Diagnosis. Since January, 1913, the Council's bacteriolcgical work has been done by the Bacteriological Department of the Seamen's Hospital, Greenwich. 608 (958 in 1917; swabs were examined for the presence of Diphtheria bacilli. In 62 (157 in 1917) the true klebs Loffler bacillus was found, and 497 were found free from either the Klebs Loffler bacillus or Hoffman's. Of the 608 swabs examined, 95 were taken from school children by the Medical Officer of Health. Of these, 14 contained the true Klebs Loffler bacillus (so-called positive cases) and 36 Hoffman's bacillus. Host of the 14 positive oases had some symptoms, viz., enlarged glands, running or sore nose, mild clinical diphtheria or follicular tonsilitis. These were notified and sent to Hospital or strictly isolated. Positive cases without any symptoms were excluded from school and from mixing with other children outside the house. Diphtheria anti-toxin is kept at the Town Hall and the Plumstead and Elthsm Free Libraries, and supplied to medical practitioners on application at cost price, or free where there is inability to pay. Last year five quantities were supplied representing 38,000 units. ENTERIC FEVER. 44. There were eight cases of Enteric Fever, not including two cases of mistaken diagnosis notified as Enteric. The caserate was 0.05, compared with 0.17, 0.05, and 0.05, in the three preceding years. For the ten years 1892-1901 the rate never fell below 0.41. The case-rate in London was 0-08. 45. There were two deaths from this disease, giving a death rate of 0.01. The death rate in London was 0.02. 15 46. The following are the oases notified in each parish during the past seventeen years (not corrected for mistaken diagnosis:- Average 1901 -5 '1906 -10 1911 1912 1913 1914 1915 1916 1917 1918 Woolwich 12.6 7.6 10 10 7 6 11 2 5 2 Plumstead 21.2 11.4 W. 3 4 3 6 13 3 2 5 E. 2 2 2 4 5 3 1 1 Eltham 8.6 2.8 1 4 2 2 2 1 4 2 One case was attributed to oysters, two to fried fish» two to visits to the seaside, one to watercress, one to direct infection by another member of the family, and one was imported from Greenwich. Two additional cases were notified as paratyphoid. Of the ten oases notified 9 were removed to a Fever Hospital, two of which were reported as mistaken diagnosis. A report was made in 1916 on the prevention of fly-carried infection of enteric fever (see Zymotic Enteritis). 47. Bacteriological Diagnosis. 14 samples of blood were sent to the Seamen's Hospital to be examined for Widal's reaction. A positive result wa6 obtained in eight. DIARRHOEA OR ZYMOTIC ENTERITIS. 48. The deaths from diarrhoea and enteritis under two years of age were 26 or 10.0 per 1,000 births, compared with 9.9, 10.7, 7.2, and 8.9, in the four preceding years. The rate for London was 15.7. The total number of deaths from these diseases at all ages was 32. Notification. Voluntary notification of zymotic enteritis during July, August and September, commenced in Woolwich in 1905. Compulsoiy notification commenced August 25th, 1913, and is unlimited as to season 118 cases were notified in the past year, compared with 173, 80, and 101 in the three preceding years. Twelve cases were notified from January to May; 4, in June; 5, in July; 45, in August; 49, in September; 2, in October; and 1, in November. 16 The fatality rate (deaths under two years per 100 notified cases under two) was 22.0 compared with 20.7, in 1917. The high fatality of the two past years probably points to neglect to notify mild oases rather than to prevalence of a type of disease severer than usual. Medical men, being specially pressed owing to the was forget that this disease is notifiable, in spite of a circular reminder being sent every year. Summer Quarter. For the first time in recent years Woolwich nad a higher diarrhoea death-rate in July-Sept, than London, viz., 29.6, compared with 27.6. The infantile death-rate from all causes was also exceptionally high in the third quarter, viz., 105, compared with 85, in London. The three Boroughs - Hampstead, Stoke Newington and Woolwich — which usually have the lowest infantile death-rate, all had an exceptionally high rate in the summer Quarter of 1918, Hampstead being the highest, viz, 116, 49, The temperature of the summer quarter was below the average and the rainfall above, conditions usually producing a low summer death rate. ZYMOTIC ENTERITIS AND METEOROLOGY — Summer quarter. 1915 1916 1917 1918 Number of cases notified 142 80 101 99 Number of deaths 12 14 12 15 Mean temperature of air 60.7 60.9 61.7 60.5 Mean temperature 3 feet below ground 60.6 59.9 62.6 — Mean humidity 80 83 81 78 Number of days on which rain fell 35 42 47 51 Rainfall in inches 8.5 6.0 3.4 13.0 Number of hours bright sunshine 541 — 580 525 ERYSIPELAS. 50. There were 61 cases of erysipelas notified, compared with 138, 95, and 79, in the three preceding .years. There were 2 deaths. The case-rate was 0.42, the lowest recorded, and the death-rate, 0.01, much below the average. These rates have been remarkably low since 1915, The London case-rate was 0.50 and the London death-rate 0.02. 17 CEREBRO-SPINAL MENINGITIS. 51, 46 cases occurred in 1915, 17 in 1916, 17 in 1917 and 7 in 1918. In addition 4 oases of post basic meningitis were notified. There were 7 deaths (6 Cerebro-spinal meningitis and 1 Dost basic meningitis) 4 of which were under five years of age. Four cases occurred in Woolwich parish and one in each of the other registration districts. None of the cases were soldiers. Four cases were removed to the fever hospital, two of which were stated to be mistaken diagnosis. Several doubtful oases were seen by the Medical Officer of Health, on request of the medical attendant, and when the former had any doubt as to the diagnosis, a bacteriological examination was made. PUERPERAL FEVER. 52. There were 14 cases of Puerperal' Fever notified compared with 8, 7, 6, 16, and 12, in the five preceding years. There were nine deaths. The case-rate per 1,000 births was 5.43, compared with 2.14, 5.20, and 4.44, in the three preceding years. The death-rate was 3.49 compared with 1.07, 1.13, and 2.22, in the three foregoing years. The London case-rate and death-rate per 1,000 births were 2.22 and 1.24 respectively. INFLUENZA. 53, A serious epidemic of Influenza was the principal feature of the year's mortality. There were 454 deaths from Influenza in the past year, 201 being males and 253 females. 4 deaths occurred from January to March, and 6 from April to June. From July to December the number of deaths occurring each week were as follows:- July August September October November 6 13 20 27 3 10 17 24 31 7 14 21 28 5 12 19 26 2 9 16 23 30 8 7 7 3 1 1 3 3 20 98 114 80 32 21 15 December 7 14 21 28 16 4 6 5 Total: 417. The following table compares the age distribution of total deaths with those of Influenza:- 18 Age Period Under 1 1-5 5-10 1015 15- 20 20- 25 25- 35 3545 45- 55 5565 6575 75 and over Total Deaths 268 169 80 57 73 89 232 206 217 223 234 344 Influenza 11 31 36 21 35 33 131 57 43 21 23 12 The largest number of deaths was in the decennium 25-35. 131 of the 232 deaths which occurred at that period were from Influenza. The proportion of deaths from Influenza to total deaths was exceedingly high between the ages of 5 and 35, but diminished rapidly from 35 onward. Only 11 of the 268 deaths under 1 year were from Influenza, and only 35 of the 478 deaths over 65. The 454 deaths compare with 35, 25, 33, 29, and 29 in the five preceding years. The increase, therefore, in 1918 was a sudden one. The earliest record of cases occurring in October was in the Women's Hostel, Eltham, on October 7th. The outbreak may be said to have lingered on into the present year. Inquiries were made at some 32 houses where deaths occurred, and 14 others where cases occurred. These houses contained 295 persons, 146 of whom had Influenza during October-December. Incubation. It was found that the average interval between the first and second cases was three day6, where only one family was involved, but where the second case was in a different family, occupying the same house, the average interval was seven days. The shortest interval where one family only was involved was 36 hours, and the longest 7 days. Of the 221 inmates of the houses visited, which were occupied by only one family, 108 were affected with Influenza, and of the 74 inmates of houses occupied by two and more families 38 were affected , showing that the occupation by more than one family did not materially increase the number of persons affected. No doubt the houses occupied by two families were more crowded than those ocoupied by one family. Of the 32 deaths 15 were suffering from some serious preexisting disease or severe overwork. Out of 76 persons who had Influenza in October and November only one had it in .Tune and July. 6 persons were met with who had Influenza in July. All these were found to have escaped in October and November. The evidence as t'o a certain amount of protection afforded by a recent attaok is therefore strong. As regards density of population of houses where the disease occurred, the average number of persons to a room was 1.33. There 19 were only three houses with less than 1 to a room. One nouse had 15 persons in four reams, but this was the only case that could be called illegal overcrowding. Institutions, Inquiries were also made as to the occurrence of Influenza in. Ootober and November at certain Institutions. In the Town Hall» out of a staff of 126, 24 were attacked. At the British Hospital for Mothers and Babies 13 out of 31 were attacked, at the Free Church Hostel 3 out of 25, at the Women's Hostel, Eltham, 245 out of 1,409, at the District Nurses' Home 6 out of 9. and at the Avery Hill Training College 100 out of 351. Those who attended on the sick were evidently therefore badly affected, but the incidence appears to have been only about 1 in 6 among munition workers, 1 in 5 in municipal employment, and nearly 1 in 3 in a training college. One might therefore say that, roughly, in institutions not specially for the sick 1 in 6 were attacked. The contrast between this low incidence in institutions and the high incidence (nearly one in two) at the houses in which deaths occurred is striking. At-the Women's Hostel, Elthon, 185 had Influenza in June and July, and 245 between,October 7th and December 13th. One died in the first outbreak and 4 in the second, giving a total fatality of 1 per cent. The fatality at the Training College was loss. Every case at the Hostel as it occurred was removed to the Hospital of the Hostel, which had its own medical and nursing staff. Nine-tenths of the inmates were said to be under 40 years of age, Those who died varied in age from 26 to 50. Only two cases affected in June and July were attacked a second time in October-Deoember. One of these had it slightly and the other badly. The Canteen Staff were affected with special severity, perhaps because they are more confined than the others. The incubation, where this could be determined, was noted to be about two days., but the infection appeared to take place at work rather than in the Hostel, At the British Hospital for Mothers ana Babies , out of 31, inmates, 4 had it in July and 13 from October to January; none died: all inmates over 40 escaped. Only 3 appear to have been infected inside the building. Fatality-. Out of the 146 cases at the houses visited there were 32 deaths, giving a fatality of 22 per cent, Only private houses where deaths occurred were visited so that the numbers are 20 • not strictly comparable. Still, the numbers offer a striking contrast with the fatality at the Hostels and British Hospital. No doubt it is partly accounted for by the different age distribution, but the fact of the two Institutions securing better ventilation and isolation, together with immediate treatment, no doubt very largely accounts for the difference. SUMMARY 1. There were 454 deaths from Influenza in 1913, 26 in June and July, 417 in October to December. 3. The chief incidence was at the ages from 5 to 45, and females were more affected than males. 3. The incubation was mainly two or three days, but varied from 36 hours to 7 days. 4. A previous attack in June or July offered considerable protection against attack in October-December. 5. The proportion of attack at Institutions varied from two in three to one in eight, nurses being; the most heavily attacked. 6. The fatality at Institutions was about 1 per cent, and in houses where deaths occurred 22 per cent. 7. Strong evidence was obtained from medical men, and at the institutions, that open-air treatment diminished fatality, BRONCHITIS AND PNEUMONIA. 5.3a. Bronchitis and pneumonia caused 345 deaths, compared with 253, 285, 380, 290, and 294 in the five preceding years. There was some increase in the deaths from bronchitis and pneumonia in adults and great increase under five years. The increase in children was probably due to increased mortality from whooping cough and Influenza and in adults to Influenza. As with Influenza the increase was chiefly in females The following table shows the figures from 1909 to date:- 1909 -12 1913 1914 1915 1916 1917 1918 Pneumonia over 5 61 63 78 99 98 95 140 Bronohitis over 5 80 120 113 160 135 113 90 Bronchitis & Pneumonia, under 5 68 70 94 121 57 86 113 Bronchitis & Pneumonia over 5 153 183 191 259 233 208 230 Bronchitis and Pneumonia Males - 144 149 196 150 161 162 ,, ,, ,, Females - 109 136 184 140 133 186 21 •' " TUBERCULOSIS. 54. Deaths. There were 225 deaths from Tuberculous disease, giving a death-rate of 1.54, compared with 1.69, 1.68, 1.72, 1.48 and 1.41, in the five preceding years. 55. The following table gives the number of deaths from each of the various forms of tuberculosis in the past 18 years and also the deaths from simple Meningitis:- Average. 1901 -5 1906 -10 1911 1912 1913 1914 1915 1916 1917 1918 Tuberculous Meningitis 20.0 22.8 20 23 14 29 18 19 19 10 Simple Meningitis 22.0 15.0 16 13 10 15 16 9 4 12 Tuberculosis of Intestines and Peritoneum 13.0 10.8 5 5 10 13 5 5 1 12 Tuberculosis (other forms) 20.8 22.2 29 16 10 11 8 12 18 9 Phthisis 192.0 151.4 146 124 182 163 201 167 172 194 56. The deaths from phthisis were 194, giving a death-rate of 1.32, compared with 1.42, 1.27, 1.49, 1.82, and 1.17 in the five preceding years. The rise and fall of the phthisis death-rate in recent years has been parallel with that of bronchitis and pneumonia. In each case 3/912 showed a minimum, and the three subsequent,years a marked rise. London had the highest death-rate since 1905. Deaths - Phthisis (Tuberculosis, ! -Junes ) 1891-5 1896-1990 1901-5 106-10 111-15 1916 1917 1918 No .Rate Aver. No.pr. year Rate Aver, No.pr. year Rate Aver No.pr. year Rate No Rate No Rate No Rate .. No, Rate Woolwioh Parish - 2.80 92 2.23 89 2.15 56 1.46 65 1.70 63 1.88 55 1.64 59 1.76 West) 51 1.22 57 1.32 60 1.39 65 1.51 Plumstead ) - 1.78 92 1.42 97 1.34 87 1.20 East) 39 1.20 31 0.86 41 1.04 44 1.32 Eltham Parish ... - 9 1.28 6 0.63 8 0.64 9 0.58 ,16 0.66 16 0.53 26 0.86 The Borough London — - 193 1.74 192 1.56 151 1.22 164 l.28 1167 l•22 172 1.17 194 1.32 - 1.88 - 1.80 - 1.57 - 1-33 _ 1.37 _ 11.46 - 1.58 - 1.69 22 Eltham has persistently had the lowest phthisis death rate of the four registration divisions, the rate being usually only one half that of the Borough. 57. The decrease of deaths from tuberculous meningitis was maintained, but there was an increase of deaths from abdominal tuberculosis. 58. Notification Statistics. 660 casep were notified (excluding: second notifications), viz., Tubercle of Lung 563, Tuberculous Meningitis 6, Tuberculosis of the Intestines and Peritoneum 14, other foms 77. The 563 notified oases of phthisis compare with 400, 420, 392 and 448 in the four preceding years. 20 were notified by the Medical Officers of the Poor Law Union, 30 by the Medical Officers of the Royal Arsenal, Army and Navy, 311 from Hospitals and Dispensaries, (including 295 from the Woolwich Tuberculosis Dispensary) 39 by the National Service Medical Board, and the remainder by private practitioners. £15. 0.6 was paid during the year for the notification of tubercu11osis . 59. Duration. Of the 660 cases notified during 1918 at least 70 have since died, and of 543 cases notified during 1°17 at least 116 have since died (January 1918). 60. The source of infection of the notified cases was probably as follows Family or personal:- Father 35 Mother 24 Brother 25 Wife 7 Son 2 Daughter 4 Sister 16 Husband 5 Members of family not defined 34 152 Workshop and Office 26 Navy and Army 44 Undetermined 340 23 61. Age and Sex distribution. The following table, required by the Local Government Board, gives the age and sex distribution of pulmonary and non-pulmonary cases, and shows also the source of notification. METROPOLITAN BOROUGH 0F WOOLWICH PUBLIC HEALTH (TUBERCUL0SIS ) REGULATIONS, 1912. Summary of Notifications during the year 1918. Age Periods Number of Notifications on Form A. from Private Medical Practitioners Total Notifications i.e., including cases previously notified by other doctors. Number of Notifications on Form B from School Medical Officers Number of Notifications Form C. Primary Notifications 65 & upwards Total . . Primary Notifications Poor Law Institutions Sanatoria 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 55 to 65 Under 5 5 to 10 10 to 15 Total Total Notifications i.e., including cases viously notified by other doctors. Pulmonary Males — 10 38 20 42 35 84 98 25 12 6 370 387 — — — — — 20 135 ,, Females 2 2 19 12 28 39 40 24 11 14 2 193 194 — — — — — 21 73 Non-Pulmonary Males 2 15 10 12 6 2 11 4 — 2 — 64 66 — 1 — 1 3 3 5 ,, Females — 6 7 10 2 2 3 1 1 — 1 33 33 — 2 1 3 3 3 2 Total 4 33 74 54 78 78 138 127 37 28 9 660 680 — 3 1 4 6 46 215 62. Visiting. The method of following up cases was described in the Annua1 Report 1915. 63. Racterio1ogica1 Diagnosis. Sputum from 266 cases of suspected phthisis examined at the Seaman's Hospital and tubercle bacilli found in 57 cases. The number of examinations for the five preceding years was 231, 273, 254 269 and 286. In addition, the Medical Officer examined 119 specimens of sputum at the Tuberculosis Dispensary, 27 being found positive. 64. Disinfection was performed by the Public Health Department at 353 premises compared with 243, 217, and 301, in the three preceding years. Disinfection was performed after the death of the patient, and also after removal to hospital, sanatorium, or other occasion of the house or bedroom being vacated. 65. Sanatorium Treatment. Altogether 261 notified persons were admitted to some sanatorium or hospital for the treatment of tuberculosis. The following table shows the number sent to the chief institutions:- CASES ADMITTED AS IN-PATIENTS TO SANATORIA, HOSPITALS, ETC. 1918. Male Female Total Infirmary 23 23 46 Downs Sanatorium 56 — 56 Northern Hospital (Winchmore Hill) 2 26 28 Nay land Sanatorium and Maltings Farm 16 5 21 Ventnor 13 6 19 Brampton Hospital and Frimley 14 12 26 All others 39 26 65 Total 163 98 261 There were fewer admissions to the Infirmary, but an increase of cases treated at Sanatoria. There was again much, delay in obtaining Sanatorium treatment. On the average the non-insured patients who finally were admitted had waited 8 weeks before going to the Sanatorium. 25 66. Shelters for Consumptives. The use and provision of these shelters has been described in previous Reports. There are 13 shelters available. Two are now occupied by men and four by women. Shelters were lent to 20 persons last year, 12 men and 8 women. Most of the patients using shelters are under the supervision of the Tuberculosis Dispensary. £8. 6, 3 was paid as shelter rent during the year. Three bedsteads with bedding are also being lent to needy cases too poor to provide such. 67. Tuberculosis Dispensary. A Dispensary for the treatment "if tuberculosis was""opened in September 1911. The following is the summary of the work referring to the period 1st. January to 31st. December 1918:- Insured persons treated 797 Uninsured ,, ,, 1,586 In attendance on January 1st. 1918:- Insured Uninsured. 314 552 Total attendances year ending December 31st. 12,360 Number of new patients examined 1,415 ,, with definite pulmonary tuberculosis 353 ,, with surgical tuberculosis 35 ,, of suspect and observation cases 508 ,, found non-tuberculous 519 ,, of home visits of medical officers 1,475 ,, ,, ,, ,, ,, nurses 1,946 ,, sputum examinations 119 ,, found positive 27 ,, of children new cases 670 ,, of contacts examined 495 There was a diminution in the number of contacts and of new cases examined, and an increase in the number of those found definitely tuberculous. The Medical Officer of Health acts as Administrative Tuberculosis Officer, and is a member of the Tuberculosis Dispensary Committee. 26 The Borough Council's scheme for the Treatment of Tuberculosis — particularly for the provision of a Tuberculosis Dispensary — was set out in the Annual Report for 1914. The work of the Tuberculosis Care Committee was described in the Annual Report for 1915. CANCER, 68. There were 161 deaths from Cancer (malignant tumour) giving a death rate of 1.10, compared with 1.06, 0.90, 0.95 and 0.38, in the four preceding years, 79 of the deaths were in males and 82 in females. 85, or nearly half the deaths, were in persons between 45 and 65. The highest mortality was in Woolwich parish. The death-rate in London was 1.27. There were 8 deaths from sarcoma and 155 from carcinoma. The deaths from carcinoma have been classified under the organs affected, since 1903, and the following table shows the result for males and females respectively:- Carcinoma. Males. Seat of Primary Disease Aver, 19035 Aver, 1906 -10 Aver, 1911 -10 1916 1917 1918 Head and face 1.7 1.2 1.2 3 1 5 Mouth, jaw and tongue 4.0 4.8 7.2 7 4 9 Pharynx, oesophagus, larynx and nock 5.0 8.6 10.4 8 11 16 Pleura, lung, mediastinum 0.3 0.4 0.4 – – 1 Stomach and Pylorus 5.3 10.4 9.2 14 13 15 Intestines (excluding rectum) 2.7 3.2 4.6 4 8 2 Rectum and anus 4.0 4. 8 5.8 5 3 12 Peritoneum, omentum and liver 8.7 6.4 7.0 3 6 8 Kidney and Bladder – 1.6 1.8 3 3 3 (Genital organs – – (Prostate and external urinary 2.7 0.8 2.8 – 2 – Pancreas 0.3 1.4 1.8 3 2 1 Undefined and all other 0.6 2.2 2.2 1 1 3 35.3 45.8 54.4 51 54 75 27 Females. Seat of Primary Disease Aver. 1903 -5 Aver. 1906 -10 Aver. 1911 -15 1916 1917 1918 Head and face 0.7 1.4 0.6 1 2 – Mouth and tongue 1.7 0.6 0.6 1 – 2 Pharynx, oesophagus, larynx and neck 1.7 1.4 2.0 – 2 6 Pleura, lung, mediastinum 0.7 0.6 0.6 1 – – Stomach and Pylorus 5.7 7.6 9.0 5 11 7 Intestines (excluding rectum) 0.7 4.2 4.2 4 7 8 Rectum and anus 3.0 6.8 6.8 7 2 3 Peritoneum, omentum and liver 7.3 9.0 8.4 14 14 11 Kidney and bladder — 1.2 1.0 – 2 2 Genital organs 16.0 13.6 14.0 23 15 22 Breasts 9.7 8.6 13.6 14 12 14 Pancreas — 0.2 0.8 – – – Undefined and all other 1.4 2.0 2.8 1 5 3 48.9 57.2 64.4 72 79 [ 78 Last year had the highest recorded cancer death-rate. The increase was chiefly in men and in oases of the face and digestive tract from the mouth to the anus. 69. Causes of Cancer. The special inquiry into the habits of persons suffering and dying from cancer since 1912 was continued. For the scope of this and the standards taken, see previous Annual Reports. The following gives the parts affected for males and females:- Carcinoma. Cases specially investigated and parts affected. Seat of Primary Disease Male Females Total Face, mouth, jaw and tongue 35 9 44 Pharynx, Oesophagus, Larynx and Neck 43 7 50 Stomach and Pylorus 30 23 53 Intestines (excluding Rectum) 16 15 31 Rectum and Anus 18 17 35 Liver 9 4 13 Breasts — 8 8 Uterus – 4 4 All other 11 2 13 162 89 251 28 Cancer Cases. 81 of the patients were stated to be excessive users of alcohol, 22 took the standard quantity, and 133. below the standard There were thus 34 per cent of excessive alcohol drinkers. 98 smoked excessively, 19 consumed an average quantity of tobacco, and 115 below the average, giving 42 per cent of excessive smokers. 69. were excessive tea drinkers, 95 moderate and 57 small tea drinkers, giving 31 per cent of excessive tea drinkers, 104 were large eaters. 77 moderate and 53 small eaters, giving 44 per cent large eaters. 75 were large meat eaters, 89 moderate and 61 small meat eaters, giving 33 per cent of large meat eaters. 138 had a daily action of the bowels, and 46 suffered from constipation, giving 75 per cent of persons with a regular action. Control or Non-Cancer Cases. These oases may be compared with those obtained for 234 persons of similar or greater age, living under similar circumstances, who did not die of Cancer. Of these –41 took alcohol excessively, 25 took the standard quantity and;154 below the standard, giving 19 per cent excessive drinkers. 46 smoked excessively, 19 in moderation, ana 145 were non-smokers or slight smokers, giving 22 per cent of excessive smokers. 66 took tea excessively, 96 in moderate amount, and 53 were small tea drinkers, giving 31 per cent of excessive tea drinkers. 179 had a regular daily action of the bowels, and 27 suffered from constipation, giving 13 per cent of constipation, Camparison. It will be seen that, comparing persons who suffer from dancer with those living at advanced ages , or who died at advanced ages through other causes, the great differences are as to habits with respect to alcohol, smoke, and the action of the bowels, thus:- Cancerous persons had 34 per cent of excessive alcohol users, 42 per cent excessive smokers, 31 per cent excessive tea drinkers, and 25 per cent of constipation. 29 - ■ Non-cancerous persons, living to a greater age, had 19 per cent of excessive alcohol users, 22 per cent excessive smokers, 31 per cent excessive tea drinkers, and 15 per cent of constipation. Mouth and throat. These differences are still more marked with respect to Alcohol and Smoking if only those who died from cancer of the mouth and throat are considered. Of 103 persons dying from Cancer of the lips, tongue, jaws, fauces, larynx, oesophagus and cervical glands, 46 (or 45 per cent) took alcohol excessively, while 73 (or 71 per cent) smoked excessively. 28 of these smoked chiefly a clay pipe, 27 a briar, 3 cigarettes and 3 cigars. There were only 5 out of the 37 oases of cancer of the mouth and tongue who did not smoke; 3 of these had bad teeth. Among the non-cancer cases all the smokers smoked pipes (42 clay and 25 briar, and 5 both;, except two who smoked cigarettes. Of 161 cases with cancer of other parts than the mouth and throat, 39 (or 24 per cent) took alcohol excessively, and 36 (or 22 per cent) smoked excessively. It would appear, then, that both alcohol and smoking (especially alcohol) have some general effect in promoting cancer, but ohiefly exert their injurious influenoe looally. This is shown also as regard alcohol by the figures given below for cancer of the stomach, which occupies an intermediate position. Of the 103 cases of cancer of the mouth and throat, 28 (or 27 per cent) were excessive tea drinkers. Tea drinking does not seem to be specially injurious locally or generally as far as cancer is concerned. If the injurious effect of smoking were chiefly due to the local effect of heat one would have expected excessive drinking of hot tea to have had a similar result. Of 13 cases of cancer of the stomach, 8 were large eaters and 2 were large meat eaters. Of 52 cases of Cancer of the stomach 16 (or 31 per cent) were excessive alcohol drinkers. As regards cancer of the bowels, out of 59 persons dying from cancer of the intestines, 32 had a regular daily action, and 26 had constipation, i.e., 44 per cent had constipation. Thus oonstipation seems to predispose to cancer of the bowels. The following table gives the above results in tabular form:- 30 ' ' ' All Cancer Oases Per cent Cancer of Mouth and Throat Per cent Cancer of other Parts Per cent Control Cases (NonCancer) Per cent. Excessive alcohol drinkers 34 45 24 19 ,, smokers 42 71 22 22 ,, tea drinkers 31 27 34 31 Constipation 25 — — 13 ALCOHOLISM. 70. There were three deaths from alcoholism and 6 from cirrhosis of the liver, making a total of 9 deaths probably due to alcohol, compared with 18, 31, 45, 38, and 22, in the five preceding years. Of the 9 deaths, 5 were males and 4 females. The rapid diminution of alcoholism during the past three years is a strong argument for continuing the restriction in the sale of alcoholic drinks which began in 1916. 71. The death-rate from alcoholism, peripheral neuritis and cirrhosis of the liver was 0.06, which is by far the lowest rate recorded for Woolwich. Syphilis. 72, There were 8 deaths from Syphilis, compared with 9, 9, 6, 5, and 7, in the five preceding years. One of these occurred in a public institution. Only one was an infant under one year. There were in addition 26 deaths from general paralysis, ta???es dorsalis (locomotor ataxy) and aneurism (diseases which are considered to be due to syphilis) compared with 23, 27, 17, and 14, in the four preceding years. Contrary to general expectation there is no sign of increase of this disease owing to the War. OPHTHALMIA NEONATORUM. (Inflammation of the eyes of the new-born. The bad eases are usually due to Venereal Disease in a parent). 31 s ' 73. Notification of this disease is compulsory on Medical men. under the Public Health (London) Act, and on Midwives under a Local Government Board Order. Midwives are paid 1/- for each case notified, 23 case's were notified compared with 18, 19, 33 and 41, in the four preceding years. The case-rate was 9.0 per 1,000 births compared with 15.2 in 1917. Four cases were removed to hospital and 5 were treated as hospital out-patients. The others were all reported to be reviving effectual treatment at home. The district nurses attended. It is doubtful whether the increase of notifications in the past three years represents an increased prevalence of the disease or only greater vigilance and notification of milder capes. Severe cases are exceptional. PART II. ADMINISTRATI0N. WATER SUPPLY. 1. No house was reported to have an insufficient water supply as regards provision of pipes and taps. 2, Defective and foul storage cisterns were found and remedied at nine houses, compared with 40, 44, and 49, in the three preceding years. At 38 houses the supply was found insufficient or temporarily cut off, and the necessary steps taken for obtaining a proper service. FOOD AND DRUGS. 3. 399 samples were submitted to the Public Analyst, and 13 or 3.2 per cent were found to be adulterated, compared with 5.6, 7.3, 7.9, 9.4, and 7.2, in the five preceding years. 246 of the samples taken were informal — 4 of these were found to be adulterated. 4. Proceedings were taken in 9 cases, fines were inflicted in 6 cases, and in 3 there was proof of warranty. 5. £73 was imposed in fines and over £11 in costs. Though these fines are greater than those imposed in former years they are not enough to deter the dishonest tradesman. the such was convicted a second time in the year of repeating the same offence of adding water. 32 140 of the samples were fresh milk. 13 of these, or 9.3 per cent were adulterated, compared with 7.9, 9.7, 10.0, 5.9 and 7.6 in the five preceding years. 18 samples were bought as butter and none were found to be adulterated. None of the other articles analysed were found to be adulterated. 5. Milk and Cream Regulations. All the milk samples were examined for the presence or preservatives and colouring; matter, but none found. The unrestricted sale of cream was prohibited during most of the year. FOOD INSPECTION. 6. There were 80 surrenders of unsound food including 33 of beef, 5 of corned beef and 8 of herrings and kippers. Over 12,000 lbs. of tuberculous and unsound beef was surrendered, and over 1,600 lbs. of herrings. The time of Inspectors Tedham, and Shaw and of Chief Inspector Duck was mainly occupied with Food Control work and they were successful in detecting a large number of breaches of the Controller's Orders. DAIRIES, COWSHEDS AND MILKSHOPS 7. On January 1st. 1918, there were 96 milkshops on the register; none were added and 12 removed, during the year, leaving a total of 84 on the register at the close of 1918. There were 104 inspections made, and 2 notices were served. There were no prosecutions. 8. Two cowsheds were added to the register, leaving 14 on the register. There were 33 inspections, and 5 notices were served for dirty conditions, etc. slaUghter-houses, 9. The number of slaughter-houses on the register remained the same, viz., 9. 36 inspections were made and 3 notices served and complied with. 33 NUISANCES. 10. 437 complaints of sanitary defects were received and investigated, compared with 614, 599, and 549, in the three preceding years. 55 complaints of non-removal of dust were made and attended to, compared with 43, 74, and 81, in the three preceding years. 11. Drains and Water-Closets. 208 private drains, found choked and defective were examined, cleared, and re-laid, compared with 475 , 440, and 291, in the three preceding; years. The largest number, 46, was found in St, Nicholas Ward. 924 water-closets and W.O. cisterns were repaired, compared with 843 , 750, and 213, in the three preceding years, 162 foul W.0. pans were cleansed by tenants, compared with 205, 151, and 157, in the three preceding years. 12, House Inspection. 2,754 houses were inspected house-to-house, compared with 4,707 , 5,736, and 4,251, in the three preceding years; 4,362 were inspected re infectious diseases and complaints, compared with 7,207, 6,423 and 5,392. In addition to these 656 inspections of registered houses were made. 13. At 1,384 houses, interiors were cleansed, or defective roofs repaired, compared with 2,703, 3,906, and 1,913, in the three preceding years, 272 houses with damp walls were remedied. compared with 646, 589, and 381, in the three preceding years. Improved ventilation was provided in 31 houses pared with 55, 72, and 15, in the three preceding years, 434 new dust pails were supplied, compared with 561, 550, and 447, in the three preceding years. 14. Medical Officer's Special Inspections. These amounted to a total of 375. 16 inspections were made of cowsheds and milkshops, 15 of bakehouses, 6 of factories and workshops, 36 inspections were on account of tuberculosis, 23 cancer, 40 diphtheria, scarlet fever, enteric, measles and whooping cough. 7 cerebro-spinal fever, encephalitis, polio-myelitis and meningitis, 53 malaria, influenza, and other diseases, and 23 infant welfare. Many of these visits were made by request of the 34 medical attendants for the purpose of diagnosing doubtful cases of infectious disease. Other visits re infectious disease were made at the request of school teachers and others. 101 premises were inspected re housing conditions and overcrowding. 34 re food and nuisances, and 16 schools and other public and private institutions. 15. Overcrowding 52 cases of overcrowding were found and remedied, compared with 97, 111, and 95, in the three preceding years. The overcrowding was 1.9 per cent of house-to-house inspections, compared with 2.1, 1.9, and 2.2, per cent in the three preceding years. 16. Smoke Nuisance. Two observations re smoke nuisances were made and no nuisance of black smoke observed. 17. Defective light. At. 21 houses new windows were supplied or existing ones enlarged, or other work done to improve the lighting by daylight, compared with 49 and 12 in the two preceding years. 18, Verminous Rooms. 104 verminous rooms were cleansed under the London County Council (General Powers) Act, 1914, or were dealt with as dirty rooms under the Nuisance Section of the Public Health (London) Act compared with 198, 213, and 568, in the three preceding years. HOUSE AND TRADE REFUSE REMOVAL. 19. There was a diminution in house refuse. In Woolwich parish 6,991 loads of house refuse, and 4 loads of inoffensive trade refuse were removed by the Borough Council, and in Plumstead 10,232 loads of house refuse, weighing 8,997 tons were removed by the Contractors, Messrs, Tuff & Hoar, and destroyed at the Plumstead Destructor, This is a decrease of over 60 per cent compared with three years ago and points to a very satisfactory decrease of waste. In addition 156 leads of trade refuse were removed to the Plumstead Destructor and destroyed (the Contractors removed 12 loads and were paid for the removal by the tradesmen at the rate of 2/- per load). £4,360, 12. 7 was paid for collection in Plumstead, compared with £3,493. 10. 2 in 1917. 35 In Eltham, the sum of £2,038. 16. 5 (£1,676. 12. 5) in 1917) was paid to the Contractors for the removal of dust. 16 loads of trade refuse were removed at the tradesmen's cost. 20. 2,317 (2,863 in 1917) receptacles of offensive trade refuse were removed. There are now 28 (24 in 1917) tradesmen on the "books. HOUSING OF THE WORKING CLASSES ACT. 21. Twelve houses were dealt with under the Housing Act, compared with 16, 6, and 4, in the three previous years. Closing Orders were made on the following 9 and 11 Market Hill, 17 and 18 Borgard Road, 51 Beresford Street, and 89 High Street. At the four latter the necessary work was done and the order withdrawn. At three other houses, the required work was done without a Closing Order being made. GOVERNMENT HOUSES AND HUTMENTS, VITAL STATISTICS. 21a. Statistics were prepared for the Government Houses and Hutments during the two years 1916/1917. The general death rate in the Government Houses for these years was 10.1, the death-rate of the hutments in 1917 (these houses were not completed until towards the end of 1916) was 7.0. HOUSES REGISTERED UNDER THE BY-LAWS. 22. At the commencement, of the year 435 houses were on the register; 13 were newly registered and none removed, leaving 448 on the register at the close of the year. 23. These houses were inspected, some quarterly, others half-yearly or yearly, 656 inspections were made in all, and 159 notices served. The registered houses were under the care of Inspectors Wood and Miss Middlebrook. INHABITED HOUSE DUTY 24. No certificate under the Inland Revenue Act was applied for. 36 UNDERGROUND ROOMS. 25. No underground rooms were found to be occupied for sleeping; contrary to the Regulations. FACTORIES, WORKSHOPS, AND WORKPLACES. 26. There were, at the close of the year 200 (203 in 1917) workshops on the register. 277 inspections were made, and 15 notices served and complied with. 119 (342 in 1917) inspections of home-workers' premises were made and 2 (7 in 1917) notices sent and attended to. Mr, Rance inspected the Factories and Workshops employing males only, and Miss Middlebrook those where women are employed. BAKEHOUSES. 27. The number of factory bakehouses is a, and of workshop bakehouses in use is 3 7. 10 of the latter being underground, They were all inspected twice. I inspected most of them personally and found them generally satisfactory. 14 certified underground bakehouses are not in use. ICE CREAM SHOPS. 28. No ice cream was made or sold. FRIED FISH SHOPS 29. There are 39 fried fish shops in the Borough. 78 inspections were made, and 17 notices served. DISINFECTION. 30. Rooms at 1,105 houses were disinfected in 1918, compared with 1,252, 989, and 1,064, in the three preceding years. The disinfecting apparatus was used 1,113 times for 22,260 articles after infectious disease, vermin, etc. Books from the Free Libraries and Schools were disinfected where necessary. 37 The sum of £10. 8. 1 was received for disinfection after illness on request of the occupier, the cases being some in which disinfection was not certified to be required by a Doctor. In addition a quantity of horsehair and blankets was disinfected for the Army Ordnance Store Department for the sum of £10. 0. 0. THE MORTUARIES. 31. The Sun Street Mortuary was used for 197 bodies, compared with 277, 271, and 185, in the three preceding; years. 173 were deposited for inquest and 24 for custody. 91 postmortem examinations were made. One body was deposited in the infectious mortuary, compared with 1, 3 and nil in the three preceding years. The Eltham Mortuary was used for five bodies compared with 3 in 1915, 8 in 1916 and 5 in 1917, all for custody. cemeteries. 32. The two Borough Cemeteries were well maintained and no complaint was received. 839 bodies were buried in Woolwich Cemetery compared with 720, 694, and 701, in the three previous years. There were 915 interments in the Plumstead Cemetery, compared with 834, 744, and 665, in the three previous years. 32 burials took place in Plumstead Churchyard, compared with 34, 51, 46, 38 and 36, in the five preceding years. cleansing OF verminous PERSONS. 33. The station for cleansing verminous persons was opened in November 1906. During 1918 it was used by 3,684 persons compared with 651, 811, 954, 1,124 and 2,800, in the five preceding years. The users were 17 adults (viz. 14 males, 3 females) and 3,667 children (viz. 1,737 females and 1,930 males). One of the adults was a soldier. 81 verminous houses were disinfected. The adults came mainly from common lodging houses and the children from County Council schools. An agreement was entered into with the London County Council, dated August 1911, to allow the London County Council to use the Borough Council Cleansing Station for cleansing school children. 38 Owing to vermin and scabies introduced by soldiers returning from abroad, there has been a great increase of cleansing required for the children. The station is now reserved for them every day except Saturday and Sunday between 9 a.m. and 4.30 p.m., girls being cleansed between 9 and 1, and boys in the afternoon. The Borough Council must properly cleanse the children and their clothes to the reasonable satisfaction of the London County Council which pays 1/- for each cleansing. The station is also now kept open for two hours each week evening and two hours on Saturday morning for soldiers. For cleansing ohildren the Borough Council employs a female attendant for the five days at a cost of 5/- per day, plus war bonus: she acts under the supervision of an L.C.C. school nurse. £178. 5. 0 was paid by the London County Council for the school children cleansed last year. A box of stavesacre ointment is supplied to each bather with instructions for its use. The names and addresses of bathers are entered in a book, and the woman inspector calls at the homes and arranges for necessary disinfection and cleansing of verminous bedding and rooms The number of children cleansed was so great as to overtax the accommodation at the station and it has been decided to provide a larger waiting room. TENTS, VANS AND SHEDS. 34, During the year 43 tents, vans and sheds were inspected (58 in 1917) and one notice served under the By-laws for this class of dwelling. 42 were in Eltham and one in St. Nicholas Ward. WOOLWICH AMBULANCES. It was found that owing to motor ambulances being now supplied by the County Council and the Asylums Board there was no longer a demand for the Woolwich horse ambulance. It was, accordingly, sold and the proceeds divided between the Nursing Association and the Invalid Children's Aid Association. 39 NOTICES AND PROSECUTIONS. 35, Fewer (2,308) intimation notices were served and 810 statutory notices. 77 of the latter not having been complied with in the time specified, were referred to the Town Clerk, who, before taking proceedings, wrote a warning letter in each case, Finally 5 defaulters were summoned at the Police Court, The results are given in Table XII. Convictions were obtained and orders made in every case. BACTERIOLOGICAL EXAMINATIONS. 36. The Council's bacteriological work is done by the Bacteriological Department of the Seamen's Hospital. 888 bacteriological examinations were made for the Public Health Department, viz,., 608 for diphtheria, 266 for phthisis, and 14 for enteric fever. The total cost was £144. 3. 0 compared with £199. 7. 0 in 1917. MATERNITY AND CHILD WELFARE. 37. (l) The staff now consists of:- An Assistant Medical Officer of Health — Dr. Rachel Mackenzie. Three Health Visitors — Miss A. Farmer, Miss K. Latham, and Mrs. M. Garside. Two more have just been appointed and will shortly start work. (2) WELFARE CENTRES are now in operation as follows:- Town Hall — Infants Consunation — Wednesday at 2.30 do Ante-natal clinic — Friday 2.30 3t. John's Church Hall, North Woolwich .Tuesday 2.30 179 Well Hall Road, Eltham Thursday 2.30 do. Ante-Natal clinic Thursday 11 a.m. The American Red Cross Welfare Centre at 289 High Street, Plumstead, on Tuesday and Friday afternoons. The Borough Council has decided to take this over from June 30th, 1919. (2A), CLINIC. Under an arrangement made with the Woolwich Branch of the British Medical Association and the London County Council, children requiring medical, surgical and dental treatment are referred to the School Treatment Centre in Brewer Street. The Borough Council pays 5/- for each case referred, 40 (3 ) HOSTEL FOR AILINS BABIES — PERRAN LODGE , EGLINTON ROAD. This Hostel was opened on the 17th December, 1918, and maintained by the Jewel Fund and a grant of £600 made by the Borough Council Accommodation is provided for 20 cases. The Staff consists of a Matron, 2 Staff Nurses,1 Nurse, 1 Probationer, Cook, Housemaid, Wardmaid, and a daily woman. A charge is made of 10/- per week per child and the patients are under the care of Dr, Dodd of Blackheath, who acts as Honorary Medical Officer. The Borough Council resolved to assume responsibility for the Hostel from the 1st, April 1919. The following four members of the Voluntary Sub-Committee have been co-opted on to the Maternity and Child Welfare Committee and act as a visiting sub-Committee. viz:- Lady Kathleen Lindsey Mrs. Callaghan Mrs, Melville-Smith Miss Gregory. (4) A DAY NURSERY was established in 1916 by the Advisory Committee for Women Munition Workers. A Special Committee was appointed with Lady Henry as Chairman and the Medical Officer of Health as a member. A grant of £100 was made by the Borough Council, The Day Nursery Committee pays £50 a year- for the services of Dr. Mackenzie, who conducts an Infant Consultation every week at the Nursery and acts as Consulting Medical Officer. Daring 1918 there was an average of 47 infants in the Nursery, viz., 15 under one year and 32 from one to five years. (5) MILK FOR MOTHERS. Under the Milk (Mothers and Children) Order, 1918,the Council authorised the Medical Officer to supply necessitous mothers and babies with milk at a reduced cost, or free of cost. 45 persons were supplied during the year, This free milk is only supplied after careful enquiries have been made into the finanoial circumstances of the family, and the Medical Officer of Health must sign the neoessary certificate. (6) DRIED MILK. Owing to the scarcity of milk during the War, the Food Controller made arrangements for the supply of Dried Milk to Local Authorities. A stock of "Cow and Gate" milk is kept in the Public Health Department and sold, at cost 41 price, to mothers attending the Welfare Centres. On an average 60 lbs. per week are sold, (7) MILK PRIORITY SCHEME. Under this scheme, put into operation by the Woolwich Food Control Committee, arrangements were made to supply milk to mothers, and children under five years of age, in priority to other customers. 2,920 cards were issued during the year, (8) BRITISH HOSPITAL FOR MOTHERS AND BABIES, This is a Maternity Hospital and school for midwives and monthly nurses. An arrangement existed by which an Ante-Natal Clinic was conducted, jointly with the British Hospital, at the Town Hall, Dr. Mackenzie acts as Medical Officer to the British Hospital. Owing to the return of the former Medical Officer of the British Hospital from war service this arrangement will shortly cease. (9) WOOLWICH AND PLUM STEAD MATERNITY HOME. This is a small home in Vicarage Park, Plum stead", managed by a voluntary Committee, containing 15 beds for unmarried mothers. It was opened on November 25th, 1918. There is accommodation for eight mothers and babies. The average number in the home is 7.8 and the average duration, of stay after the birth of a child is about two months. (10) AMERICAN NURSERY. The American Nursery at, 15 Brent Road was started a year ago for the children of women munition workers, The funds were given by the American National Allied Relief Contaittee and the furniture by the American Red Cross Commission to Great Britain. The Chairman of the Committee is Mrs. Srskine Childers, M,B.S., and the Hon, Secretary, Miss Monks. 21 infants and toddlers under 5 are taken in and there is a staff of 8, Since the armistice any babies suffering from malnutrition have been admitted. DR. MACKENZIE'S REPORT. The work done for the welfare of mothers and children is as follows:- 1. CONSULTATIONS. At these Consultations the babies are weighed and examined and the Mothers are advised as to the best means of 'keeping their children healthy. They are advised as to the importance of fresh air and cleanliness and as to the proper rules for feeding. Samples of simple clothing are also shown to them and they are encouraged to make , rather than to buy baby clothes. All the Consultations are well 42 attended and one very encouraging feature about them is the number of mothers who some saying that-they are feeding their children according to the directions given by the Health Visitors, This shows that the mothers are coming to regard Health Visitors not as Inspectors to criticise and fxnd fault but as friends to comfort, encourage and help. This shows too the tact and kindlinoss of the Health Visitors. With regard to the Plumstead Centre, the waiting room is really too small for the mothers who come. Many go away when they come and see the room full. Sewing classes for mothers have been started at Plumstead but at present not many women attend. 2. ANTE-NATAL CLINICS. There are now Ante-Natal Clinics in connection with each Infant Consultation centre. At these Clinics expectant and nursing mothers are seen and given advice as to how to keep themselves in health. They are helped with milk and dinners if necessary. Any who are found ill are advised to see a doctor or to go to hospital. These Clinics are not nearly so well attended as they should be. Until it is possible to get better supervision of the mothers before the birth of their children, we shall never get the best results in the saving of infant and maternal lives. At present it is difficult to find these women. There is no way of getting them except through doctors, midwives, or accidentally. The sympathy and co-operation of the midwives is of great importance and a good deal of time has been spent visiting and talking to them in the hope that if they know better what we are doing they will see that these clinics instead of hampering them, ought to be a great help to them. The life of a midwife is hard"; she is often misunderstood and unjustly blamed, and as a result she is apt to be distrustful of anything she does not understand. If they would co-operate more, as I feel they will in time, all the work, both theirs and ours, would be benefited. We have formed an association of midwives, which is a branch of the Midwives Institute and which meets on the last Friday of every month. At these Meetings questions of interest are discussed, and, as some of the members have asked for classes, we are hoping to arrange same for them. 3. WOOLWICH DAY NURSERY. This nursery is visited by me one morning a week. It was originally for the children of munition workers, and before the Armistice it was over-full. To that I attribute the fact that the children did not get on as well as they should have done. They are doing better now when the number of children averages 33, or only about half as many as were there before November. Influenza attacked both the Staff and the children, and the nursery had to be closed for throe weeks. There have been no other epidemic diseases there. The opening of Perran Lodge, to which the children who are ailing may be sent, is a great boon. 43 4. BRITISH HOSPITAL FOR MOTHERS AND BABIES. Two mornings weekly have been spent. there. On one of these, visits are paid to the wards, and a lecture given to the nurses who are there in training. At the last C.M.B, examination four nurses were present, all of whom succeeded in getting their Diploma. On the other mornings there is an Ante-natal clinic which is quite well attended. The attendance here shows that if midwives sent to clinic3 all their cases which require advice, the other clinics should be much larger than they are. I hope they will soon be so. Of course the women seen at the British Hospital are all patients to be attended by the midwives of the Hospital. HEALTH VISITORS' REPORTS. MISS FARMER, (Dockyard, St, Mary's, Burrage and Glyndon Wards). Visiting hemes where births have occurred has been continued as in previous years, and advice given as to feeding, clothing, and general hygiene. The mothers are invited to bring their babies to the Infant Welfare Centres , and it is surprising to note that, although every mother has received by post a card giving the times of the Centre, she generally waits for the personal invitation of the Health Visitor before bringing her child for advice and to be weighed. The attendances of children at the Infant Welfare Centre at the Town Hall have continued the seine as in previous years. It is inter sting to note this, in view of the opening of the new American Red Cross Centre at Plumstead, as it was from this district that the greater number of infants who were brought to the Town Hall come, and who now attend the new centre. The Home for Ailing Babies which was opened at Perran Lodge in December, will prove of great assistance in the work of the Infant Welfare Centres, as it will now be possible to send to the hospital infants who are not progressing properly and for whom hospital treatment is recommended. Before the opening or this hospital, not only had it proved very difficult to get young children admitted to a children's hospital, but even if a bed could' be secured this entailed a long journey with a child often in a serious condition. The milk and meals supplied in cases of necessity for mothers who are nursing their babies have proved of great benefit to many mothers and babies who are brought to the centres. 44 MISS LATHAM. (St. Nicholas, Central and St. Margaret's Wards) In connection with visits to mothers of young children, I find, in the neighbourhood of Plumstead Common, that very few are able to avail themselves of invitations to the Infant Consultations, owing to the distance of existing centres, although many express a wish to do so if there was one nearer. There is also in those mothers who do attend the Centres, a much more lively appreciation of advice given, and they do not get to regard the visits of the Health Visitor as mainly those of an Inspector, so that more good can be achieved. MRS. GARSIDE. (St. George's, Herbert and Eltham). People with young children living on the Well Hall Estate, Eltham, experienced much difficulty in obtaining a regular supply of milk even with priority tickets. In most cases there was considerable improvement after letters were sent to the respective milk sellers from the Public Health Department. Supplies of Glaxo and Cow and Gate dried milk were also erratic at the chemists. 45 HEALTH VISITORS' REPORTS, 1918. Miss Farmer Miss Latham Mrs. Garside Totals Births, visits 348 436 361 1,145 re-visits 251 284 201 736 Domiciliary visits to Infants attending Welfare Centres 108 214 125 447 Ante-natal visits 8 15 15 38 Puerperal Fever 6 5 - 11 re-visits — — — 0 Zymotic Enteritis 53 25 4 82 re-visits 3 8 — 11 Ophthalmia Neonatorum 5 7 10 22 Re-visits - 10 10 20 Tuberculosis 139 165 103 407 Measles 381 267 124 772 re-visits 27 40 2 69 Attendances at Welfare Centres plumstead - 23 — 23 ELTHAM 21 — 26 47 WOOLWICH 46 48 — 94 do. Ante-Natal Clinic 10 20 17 47 Evidence in Prosecutions 1 — — 1 Committees attended (Local Advisory and Infant Welfare Committee) 44 - - 44 Visits not otherwise classified 64 70 46 180 Unsuccessful visits, occupiers absent from home 304 362 207 873 Reported to District Inspector Structural defects 15 33 18 66 Overcrowding 2 5 7 Interior walls dirty 2 23 — 26 Other defects — 1 18 19 Infant deaths investigated - 10 — 10 Health lectures given — 1 — 1 Days at exhibition and baby show — 4 3 7 Total attendances of children at Woolwich Centre 1,172 Eltham Centre 1,040 Total attendances of Mothers at Ante-natal Clinic 152 45a WOMAN SANITARY INSPECTOR'S WORK Miss Middlebrooke reports as follows Notice should be drawn to the diminution in She numbers of verminous cases visited in 1918 as compared with previousyears. This would seem to be due to the improved financial position of the working classes earning war wages. With greater prosperity in the home,, better bedding and changes of bed clothing, better and more frequent changes of personal clothing for the family, have been provided. In less prosperous times many families have to be content with just one set of olothing, with no means of cleansing except when the children are in bed: and the spare clothing being useful to pawn it usually remains at the pawnshop most of its time. Thus it is easily seen that it is far more difficult under these circumstances to keep as clean and free from vermin as in more prosperous times. Of course even with prosperity there are dirty families whose thriftless improvident ways would never mend except under constant supervision and compulsion. These are fortunately few, but the few give a lot of trouble and cause a great many visits to be made, " Excessive drinking habits are usually responsible for this type of case. During 1918 Scabies was very prevalent amongst school children and their families, and the cleansing station was kept far busier than if we had had the normal numbers of verminous cases. A good many cases occurred in clean houses and were evidently school infeoted. Soabies is usually traceable to one of the scholars at the school having had a relative home on leave from the Front. In all the oases the bedding has either been moved for disinfection or thoroughly boiled and treated at home, or destroyed and new bedding obtained. Owing to scarcity of labour, great leniency has had to be exercised in the cleansing of walls and ceilings of Registered Houses, cleansing only being enforoed where extremely necessary instead of the frequent cleansing required by the Bye-laws, The Registered Houses were not so liable to overcrowding as in 1917, owing to more housing acconmodation being provided bv the Government. There were numerous complaints to be dealt with during 1918 of old people who were in a neglected, verminous and dirty condition. Many were old age pensioners, whose income is so inadequate now-a-days to provide even food, let alone money for attendance or cleansing purposes. The only thing for these old people seems the much dreaded Union Workhouse (after appeals to friends or relations have failed). 46 In spite of the fact that Dining Rooms and Sating Houses have been working at high pressure to supply the needs of great numbers of Munition Workers, there have been no very glaring instances of dirty conditions found. INSPECTIONS BY MISS MIDDLEBROOKE. REGISTERED HOUSES: Number of Inspections 656 „ „ Defects and dirty conditions found and remedied 530 WOMEN'S PUBLIC LAVATORIES. Number of inspections 109 ,, found defective or dirty 6 RESTAURANTS AND EATING-HOUSES. bumber of Inspections 104 ,, found defective or dirty 25 FACTORIES AND WORKSHOPS. Number of Inspections 263 ,, Notices served 17 HOMEWORKSRS' PREMISES. Number of Inspections 119 ,, of Notices served 14 MISCELLANEOUS VISITS. Visits paid for various causes, complaints, scabies, etc. 546. Visits paid to verminous cases 463 Re-visits (estimated) 1,000 Notices served on landlords and tenants re dirty conditions 205 47 STAFF — 0O0— Mrs. Garside was appointed as an additional Health Visitor in March 1918, but no other alterations occurred in the regular Staff. The time of Inspectors Tedham and Shaw, and, to a large extent of Chief Inspector Duck, was monopolised by the Food Control work. Several changes took place in the temporary female clerical staff. My thanks are due to the untiring services of Mr. Duck and the devotion of the other members of the clerical and sanitary staff; our association in work for the common welfare has lasted, in most cases, for many years and its termination will be matter of deep regret on my part. 48